Inspection·November 20, 2023

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for Micronutrient Hydration Therapy 1,000 milliliter (ml) per hour with 1,000 ml normal saline 0.9%. The order did not include the type of infusion to administer and the reason for administration. Resident #32 had an order dated 06/01/23, 07/13/23, 08/08/23 to start a peripheral IV for IV Micronutrient Hydration Therapy Cognition Infusion (Vitamin C, B-Complex, B-1, B2, B3, B5, B-6, Biotin, B-12, Magnesium Chloride, Calcium Gluconate, Zinc, Amino Blend, Glutamine, Arginine, Omithine, Lysine, Citrulline, Taurine, and Glycine) 1,000 ml with 1,000 ml of NS 0.9%. On 09/08/23, there was an order to start a peripheral IV for IV Micronutrient Hydration Therapy - Cognition Infusion with 500 ml of NS 0.9%. Review of the Medication Administration Record (MAR) revealed Resident #32 received the IV Micronutrient Hydration Therapy - Cognition Infusion with NS 0.9% on 06/02/23, 07/13/23, 08/08/23, and 09/08/23. All the IV Micronutrient Hydration Therapy - Cognition Infusion administrations were completed by an ancillary provider not employed at the facility. 3. Record review for Resident #40 revealed the resident was admitted to the facility on [DATE]. Diagnoses included hypertension, hypothyroidism, mild cognitive impairment, hypoosmolality and hyponatremia, anemia, and Parkinson's disease. Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #40 had impaired cognition. Review of the physician orders dated 03/03/23, 04/14/23, 05/11/23, 06/08/23, and 07/06/23 revealed Resident #40 had an order to start a peripheral IV for IV Micronutrient Hydration Therapy - Nutrition Infusion (Vitamin C, B-Complex, B1, B2, B3, B5, B6, B12, Magnesium Chloride, Calcium Gluconate, Zinc, Amino Blend, Glutamine, Arginine, Ornthine, Lysine, Citrulline, BCAAA, B7 Biotin, and Glutathione) 240 milliliters (ml) per hour with 1,000 ml of Normal Saline (NS) 0.9% due to poor/decreased oral intake and weight loss. Review of the Medication Administration Record (MAR) revealed Resident #40 received the IV Micronutrient Hydration Therapy - Nutrition Infusion with NS 0.9% on 03/14/23, 04/14/23, 05/11/23, 06/08/23, and 07/13/23 All the IV Micronutrient Hydration Therapy - Nutrition Infusion administrations were completed by an ancillary provider not employed at the facility. 4. Record review for Resident #42 revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, hyperlipidemia, Vitamin D deficiency, and cerebral palsy. Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #42 had intact cognition. Review of the physician orders dated 05/04/23, 06/01/23, and 07/06/23 revealed Resident #42 had an order to start a peripheral IV for IV Micronutrient Hydration Therapy -Nutrition Infusion (Vitamin C, B-Complex, B1, B2, B3, B5, B6, B12, Magnesium Chloride, Calcium Gluconate, Zinc, Amino Blend, Glutamine, Arginine, Ornthine, Lysine, Citrulline, and BCAAA) 1,000 milliliters (ml) per hour with 1,000 ml of Normal Saline (NS) 0.9%. There was no indication for use on the physician orders. Review of the Medication Administration Record (MAR) revealed Resident #42 received the IV Micronutrient Hydration Therapy - Nutrition Infusion with NS 0.9% on 05/11/23, 06/08/23, and 07/13/23. All the IV Micronutrient Hydration Therapy - Nutrition Infusion administrations All the IV Micronutrient Hydration Therapy - Infection Infusion administrations were completed by an ancillary provider not employed at the facility. Interview with the Corporate [NAME] President of Operations (CVOP) #60 on 11/20/23 at 3:40 P.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366296 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedars of Lebanon Care Center 102 East Silver Street Lebanon, OH 45036 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed she was never provided with the company's Ohio Terminal Distributor of Dangerous Drugs (TDDD) license. CVOP #60 verified the above listed residents received IV infusions of medications supplied by an unlicensed ancillary provider. All infusions ceased in September 2023 due to state licensure issues. Interview with Medical Director #70 on 11/20/23 at 4:10 P.M. verified he had ordered IV therapy for several residents in the facility according to their individual need. This therapy was meant to prevent dehydration, vitamin deficiencies, and infection prophylaxis. Medical Director #70 was not aware the ancillary provider did not have their TDDD Ohio licensure during the period of administration. Interview with representative for the ancillary provider on 11/21/23 at 2:30 P.M. verified his company does not have and had never had an Ohio TDDD license to provide medications in the State of Ohio, as he did not understand the specific Ohio laws. Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices https://www.pharmacy.ohio.gov/, dated 08/24/23, revealed a TDDD license allows a business entity to purchase, possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance. This deficiency represents non-compliance investigated under Complaint Number OH00148184. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366296 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedars of Lebanon Care Center 102 East Silver Street Lebanon, OH 45036 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, and interview, the facility failed to ensure medications were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This deficiency affected four (Residents #3, #32, #40, and #42) of four residents reviewed for medications administered by a contracted ancillary provider. This affected 16 current residents (#3, #13, #15, #17, #19, #23, #28, #30, #32, #34, #35, #37, #39, #40, #42, and #43) and one discharged resident (#45) identified by the facility who received IV fluids from the unlicensed source. The facility census was 43. Findings include: 1. Record review for Resident #3 revealed the resident admitted to the facility on [DATE]. Diagnoses included vitamin deficiency, anemia, and hypertension. Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #3 had intact cognition. Review of the physician orders dated 06/08/23 and 07/06/23, and 08/07/23 revealed Resident #3 had orders start a peripheral IV for 1,000 milliliter (ml) IV Micronutrient Hydration Therapy - Infection Infusion (for chronic urinary tract infections and infections) (Vitamin C, B-Complex, B1, B2, B3, B5, B6, Zinc, Amino Blend, Glutamine, Arginine, Ornithine, Lysine, Citrulline, Glutathione, and B7 Biotin) and 1,000 ml of Normal Saline (NS) 0.9% for fluids. On 09/06/23, Resident #3 had orders start a peripheral IV for 500 ml per hour for Micronutrient Hydration Therapy - Infection Infusion due to acute/chronic infections and 500 ml of NS 0.9%. Review of the Medication Administration Record (MAR) revealed Resident #3 received IV Micronutrient Hydration Therapy - Infection Infusion from a contracted company on 06/08/23, 07/13/23, 08/09/23, and 09/08/23. All the IV Micronutrient Hydration Therapy - Infection Infusion administrations were completed by an ancillary provider not employed at the facility. 2. Record review for Resident #32 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebrovascular disease, cataracts, Vitamin D deficiency, dementia, traumatic brain injury, and anemia. Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #32 had impaired cognition. Review of the physician orders dated 05/04/23 revealed Resident #32 had order start a peripheral IV for Micronutrient Hydration Therapy 1,000 milliliter (ml) per hour with 1,000 ml normal saline 0.9%. The order did not include the type of infusion to administer and the reason for administration. Resident #32 had an order dated 06/01/23, 07/13/23, 08/08/23 to start a peripheral IV for IV Micronutrient Hydration Therapy Cognition Infusion (Vitamin C, B-Complex, B-1, B2, B3, B5, B-6, Biotin, B-12, Magnesium Chloride, Calcium Gluconate, Zinc, Amino Blend, Glutamine, Arginine, Omithine, Lysine, Citrulline, Taurine, and Glycine) 1,000 ml with 1,000 ml of NS 0.9%. On 09/08/23, there was an order to start a peripheral IV for IV Micronutrient Hydration Therapy - Cognition Infusion with 500 ml of NS 0.9%. Review of the Medication Administration Record (MAR) revealed Resident #32 received the IV (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366296 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedars of Lebanon Care Center 102 East Silver Street Lebanon, OH 45036 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Micronutrient Hydration Therapy - Cognition Infusion with NS 0.9% on 06/02/23, 07/13/23, 08/08/23, and 09/08/23. All the IV Micronutrient Hydration Therapy - Cognition Infusion administrations were completed by an ancillary provider not employed at the facility. 3. Record review for Resident #40 revealed the resident was admitted to the facility on [DATE]. Diagnoses included hypertension, hypothyroidism, mild cognitive impairment, hypoosmolality and hyponatremia, anemia, and Parkinson's disease. Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #40 had impaired cognition. Review of the physician orders dated 03/03/23, 04/14/23, 05/11/23, 06/08/23, and 07/06/23 revealed Resident #40 had an order to start a peripheral IV for IV Micronutrient Hydration Therapy - Nutrition Infusion (Vitamin C, B-Complex, B1, B2, B3, B5, B6, B12, Magnesium Chloride, Calcium Gluconate, Zinc, Amino Blend, Glutamine, Arginine, Ornthine, Lysine, Citrulline, BCAAA, B7 Biotin, and Glutathione) 240 milliliters (ml) per hour with 1,000 ml of Normal Saline (NS) 0.9% due to poor/decreased oral intake and weight loss. Review of the Medication Administration Record (MAR) revealed Resident #40 received the IV Micronutrient Hydration Therapy - Nutrition Infusion with NS 0.9% on 03/14/23, 04/14/23, 05/11/23, 06/08/23, and 07/13/23 All the IV Micronutrient Hydration Therapy - Nutrition Infusion administrations were completed by an ancillary provider not employed at the facility. 4. Record review for Resident #42 revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, hyperlipidemia, Vitamin D deficiency, and cerebral palsy. Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #42 had intact cognition. Review of the physician orders dated 05/04/23, 06/01/23, and 07/06/23 revealed Resident #42 had an order to start a peripheral IV for IV Micronutrient Hydration Therapy -Nutrition Infusion (Vitamin C, B-Complex, B1, B2, B3, B5, B6, B12, Magnesium Chloride, Calcium Gluconate, Zinc, Amino Blend, Glutamine, Arginine, Ornthine, Lysine, Citrulline, and BCAAA) 1,000 milliliters (ml) per hour with 1,000 ml of Normal Saline (NS) 0.9%. There was no indication for use on the physician orders. Review of the Medication Administration Record (MAR) revealed Resident #42 received the IV Micronutrient Hydration Therapy - Nutrition Infusion with NS 0.9% on 05/11/23, 06/08/23, and 07/13/23. All the IV Micronutrient Hydration Therapy - Nutrition Infusion administrations All the IV Micronutrient Hydration Therapy - Infection Infusion administrations were completed by an ancillary provider not employed at the facility. Review of the facility's contract with the ancillary provider revealed the contract was entered into agreement on 01/24/23. This provided for a monthly clinic to be provided to residents with various deficiencies. The type of therapy was administered per physician orders by contracted staff through the ancillary provider. Interview with the Corporate [NAME] President of Operations (CVOP) #60 on 11/20/23 at 3:40 P.M. revealed the facilities entered into the contract with the ancillary provider on 01/24/23 and began treatment clinics in March 2023. CVOP #60 verified the ancillary provider brought their own supplies and IV products to the facility. CVOP #60 verified the ancillary provider was based out of Illinois and used their own staff for IV administration. CVOP #60 verified she was never provided with the company's Ohio Terminal Distributor of Dangerous Drugs (TDDD) license. CVOP #60 verified the above (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366296 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedars of Lebanon Care Center 102 East Silver Street Lebanon, OH 45036 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 listed residents received IV infusions of medications supplied by an unlicensed ancillary provider. Level of Harm - Minimal harm or potential for actual harm Interview with Medical Director #70 on 11/20/23 at 4:10 P.M. verified he had ordered IV therapy for several residents in the facility according to their individual need. This therapy was meant to prevent dehydration, vitamin deficiencies, and infection prophylaxis. Medical Director #70 was not aware of the ancillary provider did not have a TDDD license for Ohio during the period of administration. Residents Affected - Some Interview with Chief Executive Officer #80 from the ancillary provider on 11/21/23 at 2:30 P.M. verified his company does not have and did not ever have an Ohio TDDD license to provide drugs in the State of Ohio, as he did not understand the specific Ohio laws. He verified a Cease and Desist order was given in September 2023, and no further infusions had taken place after this order. He verified two of his nurses would come in the facility and provide services, which one had an Ohio license and the other has a reciprocal license from the state of Indiana to practice in Ohio. Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices https://www.pharmacy.ohio.gov/, dated 08/24/23, revealed a TDDD license allows a business entity to purchase, possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance. This deficiency represents non-compliance investigated under Complaint Number OH00148184. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366296 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedars of Lebanon Care Center 102 East Silver Street Lebanon, OH 45036 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices,, and interview, the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This deficiency affected four (Residents #3, #32, #40, and #42) of four residents reviewed for medications administered by a contracted ancillary provider. This affected 16 current residents (#3, #13, #15, #17, #19, #23, #28, #30, #32, #34, #35, #37, #39, #40, #42, and #43) and one discharged resident (#45) identified by the facility who received IV fluids from the unlicensed source. The facility census was 43. Findings include: 1. Record review for Resident #3 revealed the resident admitted to the facility on [DATE]. Diagnoses included vitamin deficiency, anemia, and hypertension. Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #3 had intact cognition. Review of the physician orders dated 06/08/23 and 07/06/23, and 08/07/23 revealed Resident #3 had orders start a peripheral IV for 1,000 milliliter (ml) IV Micronutrient Hydration Therapy - Infection Infusion (for chronic urinary tract infections and infections) and 1,000 ml of Normal Saline (NS) 0.9% for fluids. On 09/06/23, Resident #3 had orders start a peripheral IV for 500 ml per hour for Micronutrient Hydration Therapy - Infection Infusion due to acute/chronic infections and 500 ml of NS 0.9%. Review of the Medication Administration Record (MAR) revealed Resident #3 received IV Micronutrient Hydration Therapy - Infection Infusion from a contracted company on 06/08/23, 07/13/23, 08/09/23, and 09/08/23. All the IV Micronutrient Hydration Therapy - Infection Infusion administrations were completed by an ancillary provider not employed at the facility. 2. Record review for Resident #32 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebrovascular disease, cataracts, Vitamin D deficiency, dementia, traumatic brain injury, and anemia. Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #32 had impaired cognition. Review of the physician orders dated 05/04/23 revealed Resident #32 had order start a peripheral IV for Micronutrient Hydration Therapy 1,000 milliliter (ml) per hour with 1,000 ml normal saline 0.9%. The order did not include the type of infusion to administer and the reason for administration. Resident #32 had an order dated 06/01/23, 07/13/23, 08/08/23 to start a peripheral IV for IV Micronutrient Hydration Therapy Cognition Infusion 1,000 ml with 1,000 ml of NS 0.9%. On 09/08/23, there was an order to start a peripheral IV for IV Micronutrient Hydration Therapy - Cognition Infusion with 500 ml of NS 0.9%. Review of the Medication Administration Record (MAR) revealed Resident #32 received the IV Micronutrient Hydration Therapy - Cognition Infusion with NS 0.9% on 06/02/23, 07/13/23, 08/08/23, and 09/08/23. All the IV Micronutrient Hydration Therapy - Cognition Infusion administrations were completed by an ancillary provider not employed at the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366296 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedars of Lebanon Care Center 102 East Silver Street Lebanon, OH 45036 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Record review for Resident #40 revealed the resident was admitted to the facility on [DATE]. Diagnoses included hypertension, hypothyroidism, mild cognitive impairment, hypoosmolality and hyponatremia, anemia, and Parkinson's disease. Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #40 had impaired cognition. Review of the physician orders dated 03/03/23, 04/14/23, 05/11/23, 06/08/23, and 07/06/23 revealed Resident #40 had an order to start a peripheral IV for IV Micronutrient Hydration Therapy - Nutrition Infusion 240 milliliters (ml) per hour with 1,000 ml of Normal Saline (NS) 0.9% due to poor/decreased oral intake and weight loss. Review of the Medication Administration Record (MAR) revealed Resident #40 received the IV Micronutrient Hydration Therapy - Nutrition Infusion with NS 0.9% on 03/14/23, 04/14/23, 05/11/23, 06/08/23, and 07/13/23 All the IV Micronutrient Hydration Therapy - Nutrition Infusion administrations were completed by an ancillary provider not employed at the facility. 4. Record review for Resident #42 revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, hyperlipidemia, Vitamin D deficiency, and cerebral palsy. Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #42 had intact cognition. Review of the physician orders dated 05/04/23, 06/01/23, and 07/06/23 revealed Resident #42 had an order to start a peripheral IV for IV Micronutrient Hydration Therapy -Nutrition Infusion 1,000 milliliters (ml) per hour with 1,000 ml of Normal Saline (NS) 0.9%. There was no indication for use on the physician orders. Review of the Medication Administration Record (MAR) revealed Resident #42 received the IV Micronutrient Hydration Therapy - Nutrition Infusion with NS 0.9% on 05/11/23, 06/08/23, and 07/13/23. All the IV Micronutrient Hydration Therapy - Nutrition Infusion administrations All the IV Micronutrient Hydration Therapy - Infection Infusion administrations were completed by an ancillary provider not employed at the facility. Review of the facility's contract with the ancillary provider revealed the contract was entered into agreement on 01/24/23. This provided for a monthly clinic to be provided to residents with various deficiencies. The type of therapy was administered per physician orders by contracted staff through the ancillary provider. Interview with the Corporate [NAME] President of Operations (CVOP) #60 on 11/20/23 at 3:40 P.M. revealed the facilities entered into the contract with the ancillary provider on 01/24/23 and began treatment clinics in March 2023. CVOP #60 verified the ancillary provider brought their own supplies and IV products to the facility. CVOP #60 verified the ancillary provider was based out of Illinois and used their own staff for IV administration. CVOP #60 verified she was never provided with the company's Ohio Terminal Distributor of Dangerous Drugs (TDDD) license. CVOP #60 verified the above listed residents received IV infusions of medications supplied by an unlicensed ancillary provider. Interview with Medical Director #70 on 11/20/23 at 4:10 P.M. verified he had ordered IV therapy for several residents in the facility according to their individual need. This therapy was meant to prevent dehydration, vitamin deficiencies, and infection prophylaxis. Medical Director #70 was not aware of the ancillary provider did not have a TDDD license for Ohio during the period of administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366296 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedars of Lebanon Care Center 102 East Silver Street Lebanon, OH 45036 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with Chief Executive Officer #80 from the ancillary provider on 11/21/23 at 2:30 P.M. verified his company does not have and did not ever have an Ohio TDDD license to provide drugs in the State of Ohio, as he did not understand the specific Ohio laws. He verified a Cease and Desist order was given in September 2023, and no further infusions had taken place after this order. He verified two of his nurses would come in the facility and provide services, which one had an Ohio license and the other has a reciprocal license from the state of Indiana to practice in Ohio. Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices https://www.pharmacy.ohio.gov/, dated 08/24/23, revealed a TDDD license allows a business entity to purchase, possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance. This deficiency represents non-compliance investigated under Complaint Number OH00148184. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366296 If continuation sheet Page 9 of 9